Vol 44 # 4 December 2012 - Kma.org.kw

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295 Total Hip Replacement in Nigeria: A Preliminary Report December 2012 national income per capita of $2,069 compared to the cost of arthroplasty [9] . These factors either collectively or singly may account for the low number. Some of the patients with primary OA have some features of AVN from prolonged steroid ingestion to relieve pain. We observed male preponderance in this study. This is different from reports in literatures which show female preponderance [8] . There is scepticism on the part of our female folks on new procedures especially when it entails excision of a part and replacement with a foreign material. Pain relief is the primary indication for THR [4] . In this study, pain was the most common indication for surgery. Most of our patients were virtually on daily non-steriodal anti-inflammatory drugs for over four years. This was at a great cost for the four patients that developed peptic ulcer disease. Simultaneous arthroplasties are increasingly being performed during one single anesthetic event [10] . Two patients in this study had bilateral arthroplasty as staged operations. We were particularly worried about the effect of prolonged anesthesia and wound infection. The interval between the operations was three months. This was particularly beneficial to the patients who paid out of their pockets. Regional (spinal) anesthesia was generally welltolerated. This is particularly useful in the resourcescarce environment that we worked in; however, the incidence of post-spinal headache was high. This is similar to other reports [11] . We gave all our patients extended antibiotic therapy for two reasons. We were ‘paranoid’ about infection. Our theatre does not have laminar air- flow system and the same theatre is used for routine clean orthopedic cases. We believe that in addition to the general measures of ensuring clean theatre environment, 3 - 4 days antibiotic therapy is necessary until the procedure is well-standardized and facilities upgraded. No case of serious infection was observed in the cases so far. Also, the length of hospital stay was long. A number of reasons were responsible for this. We were unsure of the home environment for most patients. The team of physiotherapists needed the time to guide the patients before discharge. Secondly, some of the difficult case had marked muscle wasting and required considerable time for rehabilitation post operation. The need for deep vein thrombosis (DVT) surveillance and prophylaxis is well established in THR. However, the critical issue is the duration [12] . We gave our patients enoxaparin 40 mg daily for five days and continued with compression bandaging and lowdose aspirin. This corresponds to the time most of them were fully ambulant. The reason for this short duration regime was cost. We observed no case of overt DVT. This was surprisingly similar to the low incidence reported in other studies with extended duration of treatment [13] , but quite different from studies in the African-Americans [14] . References on the incidence of venous thrombo-embolism (VTE) among the blacks are commonly taken from studies on African- Americans, because there is dearth of studies among the native sub-Saharan black Africans. Our observation may be due to a number of factors. Immobility remains one of the most important factors for the development of DVT. Preoperatively, all our patients maintained their mobility despite extreme pathology and they were able to mobilize within the first two days post surgery. Secondly, most of our patients continued with low dose aspirin and compression bandaging even after enoxaparin was discontinued. Although there is strong evidence that the prevalence of VTE varies significantly among different ethnic / racial groups, the genetic, physiologic and clinical basis for these differences remain largely undefined [15] . Our finding supports the need to determine gene polymorphisms associated with VTE in Africans [16] . Posterior implant dislocation was the only major adverse event recorded and the only reason for reoperation in two patients and re-admission and reoperation in one patient. It was noted that the patients whose implants dislocated were those that had old unreduced posterior dislocation of the hip with posterior wall defect and false acetabulum as well. No mortality was recorded in this study supporting the low mortality rate associated with this procedure [17] . Technical difficulties encountered were due to the fact that our patients presented very late and so had bone defects, contractures about the joint, disuse muscles atrophy, limb length discrepancy, etc. The contractures make for difficult surgery with need to do a lot of soft tissue releases, thereby increasing post operative blood loss and operating time. Some patients who had prior surgeries like girdlestone arthroplasty or had hardware in situ following a failed internal fixation of proximal femoral fracture presented a lot of surgical challenges. Indeed, some of these cases qualify for revision or complex primary arthroplasty. As reported by Sathappan, complex primary total hip arthroplasty (THA) is defined as primary THA in patients with compromised bony or soft-tissue states, including but not limited to dysplastic hip, ankylosed hip, prior hip fracture, protrusio acetabuli, certain neuromuscular conditions, skeletal dysplasia, and previous bony procedures about the hip [18] . For the conversion of Girdlestone excision arthroplasty to THR, locating the original acetabulum without image intensifier was technically challenging. The dense fibrous tissue was also very bloody. This could therefore, be regarded as a revision hip. Conversion to total hip arthroplasty is generally accepted as the most successful procedure for failure
December 2012 KUWAIT MEDICAL JOURNAL 296 of fixation devices in hip fractures [19] . All the affected patients had a one stage procedure: implant removal and THR. Some of the cases had major bone defect that required bone grafting. In absence of a bone bank, we overcame this problem by morselizing whatever is left of the femoral head, which in some cases was badly degenerated and collapsed. Blood loss during surgery is often related to the difficulties encountered. Significant proportion of our cases was complex primary and six of them had previous surgical intervention with dense fibrosis. The average blood loss (both intra-operative and postoperative period) for our patients was 800 ml. This compares favourably with values in the literature [20] . CONCLUSION There is an absolute need to sustain the development of arthroplasty service in Nigeria as shown by the variety of cases presented. A good number of the cases are complex primary arthroplasty and most of the patients are relatively young and will outlive their implant and therefore, require revision. Therefore, in addition to development of primary procedures, investment in capacity building for revision procedures should be started now to bridge the gap. ACKNOWLEDGMENT The authors are grateful to the Medical Director, Dr CB Eze, who made it possible for the development of this new speciality at the NOHE. Also, we own a debt of gratitude to Dr Sam Orakwe, Dr Ike Nwachukwu and Johnson & Johnson for providing the initial technical support. Conflict of interest: The authors do not have any financial relationship with any of the companies manufacturing any of the products mentioned in this study. It was not supported by external funding of any sort. REFERENCES 1. Berry DJ, Harmsen WS, Cabanela ME, Morrey BF. Twenty-five year survivorship of two thousand consecutive primary Charnley total hip replacements: Factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg Am 2002; 84:171-177. 2. HarrisWH. Advances in total hip arthroplasty: The metal-backed acetabular component.Clinical Orthopedics & Related Research 1984; 18:4-11. 3. Seyler TM, Cui Q, Mihalko WM, Mont MA, Saleh KJ. Advances in hip arthroplasty in the treatment of osteonecrosis. Instr Course Lect 2007; 56:221-33. 4. Ugbeye ME, Odunubi OO. Knee Replacement: a preliminary report of thirteen (13) cases at NOHI. Nigerian Journal of Orthopedics and Trauma: 2009; Vol 8(2). Available at http://www.ajol.info/index.php/ njotra/article/view/48304 5. Wainwright C, Theis JC, Garneti N, Melloh M. Age at hip or knee joint replacement surgery predicts likelihood of revision surgery. J Bone Joint Surg 2011; 93:1411-1415. 6. Akinyoola AL, Adediran IA, Asaleye CM. Avascular necrosis of the femoral head in sickle cell disease in Nigeria: a retrospective study. Nig Postg Med J 2007; 14:217-220. 7. Hernigou P, Zilber S, Filippini P, Mathieu G, Poignard A, Galacteros F. Total THA in adult osteonecrosis related to sickle cell disease. Clin Orthop Relat Res 2008; 466:300- 308. 8. Liu Y E B, Hu S, Chan S P, Sathappan SS. The epidemiology and surgical outcomes of patients undergoing primary total hip replacement: an Asian perspective. Singapore Med J 2009; 50: 15. 9. International Human Development Indicators – United Nations Development Programme. Available at: http:// hdrstats.undp.org/en/countries/profiles/NGA.html 10. Huotari K, Lyytikäinen O, Seitsalo S. Patient outcomes after simultaneous bilateral total hip and knee joint replacements J Hosp Infect 2007; 65:219-225. 11. Macfarlane AJR, Prasad GA, Chan VWS, Brull R. Does regional anaesthesia improve outcome after total hip arthroplasty? A systematic review. Br J Anaesth 2009; 103;335-345. 12. Turpie AG. Extended duration of thromboprophylaxis in acutely ill medical patients: optimizing therapy? J Thromb Haemost 2007; 5:5-11. 13. Jain V, Dhaon B, Jaiswal A, Nigam V, Singla J. Deep vein thrombosis after total hip and knee arthroplasty in Indian patients. Postgrad Med J 2004; 80:729-731. 14. Heit JA, Beckman MG, Bockenstedt PL, et al. Comparison of characteristics from white and black Americans with venous thromboembolism: a cross-sectional study. Am J Hematol 2010; 85:467-471. 15. Dowling NF, Austin H, Dilley A, Whitsett C, Evatt BL Hooper WC. The epidemiology of venous thromboembolism in Caucasians and African- Americans: the GATE Study. J Thromb Haemost 2003; 1:80-87. 16. White RH, Keenan CR. Effects of race and ethnicity on the incidence of venous thromboembolism. Thromb Res 2009; 123:S11-17. 17. Hamel MB, Toth M, Legedza A, Rosen MP. Joint replacement surgery in elderly patients with severe osteoarthritis of the hip or knee: Decision making, postoperative recovery, and clinical outcomes. Arch Intern Med 2008; 168:1430-1440. 18. Sathappan SS, Strauss EJ, Ginat D, Upasani V, Di Cesare PE. Surgical challenges in complex primary total hip arthroplasty. Am J Orthop (Belle Mead NJ) 2007; 36:534- 5341. 19. Winemaker M, Gamble P, Petruccelli D, Kaspar S, de Beer J. Short term outcomes of total hip arthroplasty after complications of open reduction internal fixation of hip fracture. J Arthroplasty 2006; 21:682-688. 20. Sehat KR, Evans R L, Newman JH. Hidden blood loss following hip and knee arthroplasty: Correct management of blood loss should take hidden loss into account. J Bone Joint Surg (Br) 2004; 86:561-565.
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